EXECUTIVE SUMMARY
Emergency medicine poses liability risks that are unique to the field and require a targeted risk management strategy. Applying a general risk management approach will overlook potential problems.
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The unpredictability of emergency patients creates more risk than in most other clinical areas.
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Protocols for specific conditions such as heart attack should be followed closely.
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Physician extenders can improve patient flow but create unexpected risks.
It can happen in any hospital: A patient comes to the emergency department (ED) and is determined to need psychiatric care, so a bed is requested. The patient waits, and waits, and waits. Three days later, the patient is still in the ED, and staff members realize he has a blood clot and pulmonary embolism that were prompted by immobility during the long wait.
The patient suffers, the hospital incurs more costs for care, and a lawsuit is likely. That incident happened at one prominent hospital, and it is just one example of how liability risks in the ED can be more challenging than those in the rest of the facility. The ED requires a more intensive look and a specific strategy targeted to this area’s unique risks, and treating the ED the same as any other clinical area will leave huge liability exposures, say ED experts and risk managers.
Part of what makes risk manage-ment in the ED so tricky is the unpredictability of patient care, says Roneet Lev, MD, FACEP, director of operations at Scripps Mercy Hospital in San Diego and president of the Independent Emergency Physicians Consortium, which facilitates practice improvement for EDs in California. In most other clinical areas, the type of patient and treatment can be predicted and the attending risks addressed, she says, but not in the ED.
“Each patient is a land mine of risk. We don’t know what’s walking in the door,” Lev says. “A simple wound can end up being necrotizing fasciitis. I once had a patient come in with finger pain, and it turned out to be appendicitis, so you can’t assume anything is what it seems to be.”
The Doctors Company, a malpractice insurer based in Napa, CA, conducted a study of 332 emergency medicine claims that closed from 2007-2013 and found that the top patient allegation, which accounted for 57% of claims, was diagnosis-related, including failure to diagnose, delay in diagnosis, and wrong diagnosis. Similarly, physician experts who looked into the data determined that the top factor contributing to patient injury (52% of claims) was patient assessment issues, such as failure to establish a differential diagnosis and failure to order diagnostic tests. (The study is available at www.thedoctors.com/emergencymedicinestudy.)
Patient safety challenges and liability risks have increased in the ED over time, Lev says. For example, the unpredictability of patients creates more risk from the use of electronic health records (EHRs), Lev says. Although she acknowledges the benefits of EHRs, Lev says the temptation to cut and paste or use boilerplate text runs counter to the need to be skeptical and never make assumptions in the ED. Her 20 years in the field also has shown that ED patients have more complicated medication regimens than previously.
More medications, and less common medications, increase the chance of drug interactions and other medication errors, Lev notes. “Twenty years ago, patients would come in and tell me what medications they were on, and I would know all of them. Now they tell me this long list of medications, and a lot of them I don’t know and have to look up,” she says.
PSYCH WAITS CREATE RISKS
Lev also is concerned with how EDs see many more psychiatric patients and those patients stay in the ED longer than previously as they wait for placement in another unit or facility. To avoid potential problems caused by long delays while psychiatric patients wait for a bed, her hospital has instituted a protocol for psychiatric patients waiting in the ED to make sure they receive food and water, have the opportunity to walk around, and receive their regular medications.
Physician extenders provided by outside agencies also can pose liability risks because their management can be inconsistent with the hospital’s own policies and procedures, and they sometimes can make treatment too speedy and efficient, she says. For example, the use of physician extenders can make wound closure much faster, but that situation poses the risk of missing tendon injuries. The solution to that problem is to have a protocol requiring a physician to examine the wound for any further injury before the physician extender is allowed to close it, she suggests.
Strict adherence to protocols for “time to EKG” and “time to antibiotics,” for example, can significantly reduce some of the risks in the ED, Lev adds. Handoff protocols also should be followed closely, and discharge instructions should emphasize what changes or symptoms require a return to the ED.
ED risk also is exacerbated by the increasing usage of hospital EDs, says Peter D. Steckl, MD, a practicing ED physician and the risk manager for EmergiNet, an emergency medical staffing and management company based in Atlanta. Years of mergers and hospital closures have led to the remaining EDs treating more patients, and more recently the Affordable Care Act has led to more ED volume, Steckl says. That increased volume poses a challenge to patient flow in the ED, which always has been one of the greatest liability risks.
In addition, there are bed shortages and nursing shortages that can slow the placement of ED patients, which creates backup that exacerbates all the existing liability risks in the department, Steckl says.
“So we have this bottleneck with patients backing up in our department, and we’re still accepting critically ill patients. Those patients we’ll make room for, but it’s the patients who are not critically ill, or at least we don’t know they are, that suffer because we can’t bring them back. The inn is full, so they sit there in the waiting room,” Steckl says. “They’re evaluated by a triage nurse, but they can sit for hours before they’re seen by a doctor. Sometimes serious illnesses don’t present in a way that’s obvious, so there’s a definite risk of someone sitting there until suddenly you have a cardiac arrest in the waiting room.”
PROTOCOLS FOR BED WAITS
The issue of throughput in the ED must be addressed with policies and procedures that ensure patients are not neglected while waiting for a bed, says Dona Constantine, RN, a former ED nurse and senior risk management and patient safety specialist with the Cooperative of American Physicians in Los Angeles. The hospital must have a clear policy that addresses questions such as who is in charge of a patient discharged from the ED but waiting for a bed. Is it the physician the patient has been admitted to, or is it still the physician in the ED?
“There have to be real boundaries there for when that transition takes place,” Constantine says. “Communication throughout the whole continuum of patient care is very important, because communication failures are involved in a majority of malpractice claims in the ED.”
Related to communication, handoffs also are a high-risk moment in the ED and should be carried out according to a specific protocol, Constantine says. With the pressures of high volume and emergent conditions, a proper handoff can be challenging in the ED, she notes, but it should be face to face between the physicians whenever possible.
Staff members’ turnover and mobility also create additional risk. When Steckl enters the ED to begin his shift, the first thing he does is to look around and see if he recognizes any faces. “I want to know if there’s someone I can trust in a crunch,” he says. “Many days there are nurses I’ve never seen before, either registry nurses filling in or new nurses just out of school.”
Those problems can’t be solved by a risk manager, but they should be recognized as special circumstances that demand increased attention and resources, Steckl says. The risk manager can help ensure that hospital administrators understand the special liability risks in the ED and urge that overcrowding, staffing problems, and other problems be addressed in the most effective way possible, he suggests.
“We can’t expect a risk manager to solve these problems that have existed in EDs for years, but it can be beneficial to have someone besides the head of emergency medicine going to administration and asking for help,” Steckl says. “The potential liability risks can be an impetus for getting more resources in the ED.”
SOURCES
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Dona Constantine, RN, Senior Risk Management & Patient Safety Specialist, Cooperative of American Physicians, Los Angeles. Email: [email protected].
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Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital, San Diego. Telephone: (619) 203-7290. Email: [email protected].
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Peter D. Steckl, MD, Risk Manager, EmergiNet, Atlanta. Telephone: (770) 994-9326.
